Provider Demographics
NPI:1770193872
Name:PRAIRIE BLUFFS TCU, LLC
Entity Type:Organization
Organization Name:PRAIRIE BLUFFS TCU, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KREBSBACH
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:612-202-4553
Mailing Address - Street 1:10300 HENNEPIN TOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347
Mailing Address - Country:US
Mailing Address - Phone:952-444-5000
Mailing Address - Fax:952-204-3024
Practice Address - Street 1:10300 HENNEPIN TOWN RD
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-5100
Practice Address - Country:US
Practice Address - Phone:952-444-5000
Practice Address - Fax:952-204-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN409168Medicaid